[Senate Hearing 117-196]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-196

                         ADDRESSING DISPARITIES
                           IN LIFE EXPECTANCY

=======================================================================

                                HEARING

                               BEFORE THE

         SUBCOMMITTEE ON PRIMARY HEALTH AND RETIREMENT SECURITY

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                                   ON

  EXAMINING DISPARITIES IN LIFE EXPECTANCY, AFTER RECEIVING TESTIMONY 
FROM KATHLEEN MULLAN HARRIS, UNIVERSITY OF NORTH CAROLINA, CHAPEL HILL; 
WILLIAM E. COOKE, FOUNDATIONS FAMILY MEDICINE, AUSTIN, INDIANA; AND BOB 
        MACKENZIE, KENNEBUNK POLICE DEPARTMENT, KENNEBUNK, MAINE
                               __________

                             JULY 21, 2021
                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
                                
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        Available via the World Wide Web: http://www.govinfo.gov
        
                               __________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
46-776 PDF                  WASHINGTON : 2023         
        
        
        
          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                    PATTY MURRAY, Washington, Chair
BERNIE SANDERS (I), Vermont          RICHARD BURR, North Carolina, 
ROBERT P. CASEY, JR., Pennsylvania       Ranking Member
TAMMY BALDWIN, Wisconsin             RAND PAUL, M.D., Kentucky
CHRISTOPHER S. MURPHY, Connecticut   SUSAN M. COLLINS, Maine
TIM KAINE, Virginia                  BILL CASSIDY, M.D., Louisiana
MAGGIE HASSAN, New Hampshire         LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota                MIKE BRAUN, Indiana
JACKY ROSEN, Nevada                  ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico            TIM SCOTT, South Carolina
JOHN HICKENLOOPER, Colorado          MITT ROMNEY, Utah
                                     TOMMY TUBERVILLE, Alabama
                                     JERRY MORAN, Kansas

                     Evan T. Schatz, Staff Director
               David P. Cleary, Republican Staff Director
                  John Righter, Deputy Staff Director
                                 ------                                

         SUBCOMMITTEE ON PRIMARY HEALTH AND RETIREMENT SECURITY

                 BERNIE SANDERS (I), Vermont, Chairman
ROBERT P. CASEY, JR., Pennsylvania   SUSAN M. COLLINS, Maine, Ranking 
TAMMY BALDWIN, Wisconsin                 Member
CHRISTOPHER S. MURPHY, Connecticut   RAND PAUL, M.D., Kentucky
TIM KAINE, Virginia                  LISA MURKOWSKI, Alaska
MAGGIE HASSAN, New Hampshire         ROGER MARSHALL, M.D., Kansas
JACKY ROSEN, Nevada                  TIM SCOTT, South Carolina
BEN RAY LUJAN, New Mexico            JERRY MORAN, Kansas
PATTY MURRAY, Washington (ex         BILL CASSIDY, M.D., Louisiana
    officio)                         MIKE BRAUN, Indiana
                                     RICHARD BURR, North Carolina (ex 
                                         officio)


                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                        WEDNESDAY, JULY 21, 2021

                                                                   Page

                           Committee Members

Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health 
  and Retirement Security, Opening statement.....................     1
Collins, Hon. Susan, Ranking Member, a U.S. Senator from the 
  State of Maine, Opening statement..............................     3

                               Witnesses

Mullan Harris, Kathleen, Ph.D., James E. Haar Distinguished 
  Professor of Sociology, University of North Carolina, Chair, 
  Committee on Rising Midlife Mortality Rates and Socioeconomic 
  Disparities, The National Academies of Sciences, Engineering, 
  and Medicine, Chapel Hill, NC..................................     5
    Prepared statement...........................................     8
Cooke, William, E., M.D., FAAFP, FASAM, AAHIVS, Owner and Medical 
  Director, Foundations Family Medicine, Austin, IN..............    21
    Prepared statement...........................................    23
MacKenzie, Robert, F., Chief of Police, Kennebunk Police 
  Department, Kennebunk, ME......................................    25
    Prepared statement...........................................    26

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.
    The Two Trajectories of Life.................................    37
    Confornting a Legacy of Scarcity: A Plan for America's Re-
      Investment in Public Health................................    38
    Community Health and Economic Prosperity, Engaging Businesses 
      as Stewards and Stakeholders--A Report of the Surgeon 
      General....................................................    72
    Addressing Social Determinants of Health in Primary Care, 
      Team-Based Approach for Advancing Health Equity............   431

                         QUESTIONS AND ANSWERS

Response by Kathleen Mullan Harris to questions of:
    Senator Casey................................................   443
Response by Robert F. MacKenzie to questions of:
    Senator Casey................................................   444

 
                         ADDRESSING DISPARITIES
                           IN LIFE EXPECTANCY

                              ----------                              


                        Wednesday, July 21, 2021

                                       U.S. Senate,
    Subcommittee on Primary Health and Retirement Security,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 10 a.m., in 
room 430, Dirksen Senate Office Building, Hon. Bernard Sanders, 
Chairman of the Subcommittee, presiding.
    Present: Senators Sanders [presiding], Casey, Murphy, 
Kaine, Hassan, Rosen, Collins, Murkowski, Marshall, Scott, and 
Braun.

                  OPENING STATEMENT OF SENATOR SANDERS

    The Chairman. Let me call the hearing to order, and thank 
Senators who are here, and to mention that the issue that we 
are discussing today is a very sobering issue and it is an 
issue I think does not get the kind of attention that it 
deserves. And let me thank Ranking Member Collins for her 
interest in the topic.
    Let me thank Dr. Kathleen Harris, Dr. William Cooke and 
Chief of Police, Chief Robert Mackenzie for joining us for this 
hearing today. They are going to be with us virtually. You 
know, in the U.S. Congress, we have our differences of opinion, 
to say the least. But I think every member works hard on the 
issues of importance to his or her state or congressional 
district. But I think sometimes we may, in the midst of our 
work, lose sight of the big picture, the really big picture of 
what I think all of us want to accomplish.
    Very simply stated, what I want, and I believe Members of 
the Committee want, and certainly the American people want, is 
to create a Nation in which the people in the United States can 
live long, healthy, happy, and productive lives. At the end of 
the day, that is what we are fighting for. Unfortunately, the 
issue we are discussing today, as I mentioned, does not get 
nearly enough attention, but it is surely an ongoing tragedy, 
something that we need to focus a lot more, work on. And that 
is that here in the wealthiest Nation, in the history of the 
world, where we spend far more per capita on health care than 
people in other countries, the truth is that our life 
expectancy, how long our people live, trails behind many other 
industrialized countries.
    Tragically and the question of today, what we are 
discussing is life expectancy in the United States right now, 
for many, many people, is in decline. And when we discuss the 
issue of life expectancy, the real outrage, it seems to me, and 
this is above and beyond the culprit, the horrors of the COVID 
pandemic, is that not all of our society is seeing a decline in 
life expectancy. What we have seen over the last number of 
years, again, pre-COVID, is that this declining life expectancy 
is impacting lower income and working people in a very 
significant way, people with less education, and people who 
live in rural areas. In terms of life expectancy, as it 
happens, the very wealthy are doing just fine. The crisis 
impacts particular people, working people, lower income people, 
people living in rural communities.
    One of the most alarming facts, I think, that we have to 
address as a Nation is that today, and I want everybody to hear 
this, an upper income male lives 15 years longer than the 
poorest male. And the gap between women is 10 years. According 
to a report by the Health and Equality Project, from 2001 to 
2014, the wealthiest Americans gained approximately 3 years in 
life expectancy, while the poorest Americans experienced no 
gains. A three-year difference in life expectancy may seem 
trivial. What is 3 years? But as the report's authors note, 
this gain in lifespan is the equivalent of curing cancer for 
only the wealthy.
    Imagine that wealthy get cured, everybody else does not. 
Let me give you another example. If you are upper income, if 
you have stable housing, if you have access to decent medical 
care, you are doing fine. Today in Fairfax County, Virginia, 
for example, the median household income is $124,000 and the 
poverty rate is just 6 percent. A child born in Fairfax County, 
Virginia, today could expect to live to 85 years of age. That 
is pretty good. It is pretty good in terms of international 
standards. It is good. But in Scott County, Indiana, where Dr. 
Cook has his medical practice, the median household income is 
$48,000 and almost 14 percent of the community lives in 
poverty. A child born there today could expect to live only 71 
years. Imagine that, 14 year discrepancy between Fairfax 
County, Virginia and Scott County, Indiana.
    In other words, what we are discussing today, and this is 
such an important point, is poverty is like that. You, are the 
big house, I have a small house. You are driving a fancy car. I 
have a broken old car. That is not what we are talking about. 
What we are talking about is that if you are wealthy in 
America, you will live many, many more years than if you are 
poor. So it is not a question of luxuries. It is a question of 
literally poverty and stress being a death sentence. And all of 
this is preventable. And I think and hope that all of us can 
agree that this reality of today is a moral and economic 
failing. Over the past 10 years, the disparities have grown 
exponentially. And this is above and beyond the onslaught of 
the COVID pandemic, which has done, all the horrible things and 
the deaths that it has caused. As we will hear from Dr. Harris 
today, mortality is now flat or rising among most working age 
populations.
    Socioeconomic disparities have widened substantially, 
especially by education levels. People who obtained a 
bachelor's degree are doing much, much better than those who 
have not gotten that quality of education. And what makes this 
even more stark is that many of these premature deaths are 
preventable. This is not about needing more advancement in 
medical research.
    In fact, cancer death rates are declining for more than 
half of the most common cancers in the U.S. We are making 
significant progress than in another many years. This is not 
about health care. We are seeing a nationwide crisis of what 
doctors call, ``deaths of despair.'' ``Deaths of despair.'' 
What does that mean? It means that we are seeing an increase 
and will discuss the history of drug overdoses, opioid 
epidemic, alcoholism, and even suicides. A Stanford 
neuroscientist, Robert Sapolsky, who has been speaking and 
writing on this topic for decades, offers a simple answer as to 
why we are seeing this decline in life expectancy, poverty and 
economic stress is what he says. The psychological impact of 
being poor, a life of poverty can mean a life of constant 
stress.
    This is the point that I think people don't understand. It 
is not having a fancy car. It is living every single day 
wondering how are you going to feed your kids? How are you 
going to pay the rent? How are you going to prevent yourself 
from being evicted? What toll does that have on all of us? It 
is extraordinary. The poor have little control over their work 
schedules, whether they have jobs, how much money they make.
    They fear suddenly losing the job, being unable to pay 
their electric bill. What happens if your electricity goes out? 
What happens if you don't have a cell phone? They despair over 
their own future and how to give their children a better life. 
They are exhausted and socially isolated by second or third 
jobs, long commutes, and weekend shifts. They lack the means to 
take much needed time off or pay for relaxing hobbies.
    Often their social support systems are decimated by 
incarceration, addiction, and depression. And I can go on and 
on, but I think I have kind of laid the table for what I hope 
we will be discussing today. I know Senator Collins has long 
been interested in these kinds of issues. We appreciate your 
help.
    Senator Collins.

                  OPENING STATEMENT OF SENATOR COLLINS

    Senator Collins. Thank you very much, Mr. Chairman. This is 
an extraordinarily important hearing that you are holding 
today, and I appreciate your convening it. The pandemic and its 
consequences have exacerbated many of the problems that were 
already fueling declines in life expectancy. Just this morning, 
The Wall Street Journal reported that U.S. life expectancy fell 
by 1.5 years in 2020. That is the biggest decline in 
generations. And the largest drop was among Hispanic men.
    One of the clearest consequences of the pandemic is the 
escalating incidence of behavioral health problems and 
substance abuse disorders. Overdose deaths have soared by 30 
percent during the pandemic. Last year, 504 Mainers died from 
overdoses, a tragic record that exceeded the deaths caused by 
COVID-19 in 2020. Let me say that again. More Mainers died from 
drug overdoses last year than died from the tragic pandemic. 
Regrettably, 2021 may be even worse as Maine has averaged 
nearly 50 overdose deaths a month so far this year.
    Like Americans of all ages, young adults had a tough time 
coping with the pandemic, the lockdowns. And other 
consequences. And they reported much higher levels of anxiety 
in a CDC survey conducted last summer among young people aged 
to 18 to 24. Nearly a quarter reported that they had started or 
increased their abuse of substances to cope with pandemic 
related stress or emotions. The survey also revealed that 25 
percent seriously considered suicide. Many who have struggled 
with the chronic illness of addiction long before the pandemic 
found it more difficult to access the treatment they needed, to 
participate in counseling, and peer to peer support during the 
pandemic as young adults started to become parents themselves.
    The stakes have become infinitely higher. In Maine, about 8 
percent of babies born in 2018 had some degree of neonatal 
abstinence syndrome. This summer alone, a three-year old from 
Old Town died. An 11 month old from Correna suffered a near 
fatal fentanyl overdose. In 2017, the Portland Press Herald ran 
a 10 part series titled ``Lost, Heroin's Critical Killer Grip 
on Maine's People.'' And one of the installations in the series 
focused on women and the challenges that they face.
    The article said that when it comes to opioids, women are 
at a deadly disadvantage. They are dying of overdoses at 
increasing rates compared with men. They get addicted faster 
and feel withdrawal more acutely. They are often dealing with 
sexual trauma as well as their addiction. They tend to avoid 
seeking treatment if they are mothers because they fear their 
children will be taken away from them. And when they do ask for 
help, there are fewer resources available for them. One of the 
themes that we will hear today is the importance of engaging 
local communities. The structure and connection that can be 
found in employment, schooling, church, and community groups 
not only helps with identity and giving life a sense of 
purpose, but also they can be an essential source of peer 
support.
    I am very pleased that with us today is Kennebunk's Police 
Chief, Robert MacKenzie, and he will talk about his impressive 
efforts, including working with Rotary International. Another 
theme, which is near and dear to the Chairman's heart as well 
as mine, is access to health care, for example. Those working 
and highly physical and dangerous professions such as the 
lobster fishing industry, for them, the time and travel to take 
care of anything other than emergency health care needs can 
deter them from seeking regular care for conditions like high 
blood pressure and diabetes.
    Last year, I joined a bipartisan group of Senators in 
introducing legislation to expand Telemental Health Services in 
rural areas, the home based Telemental Health Care Act would 
establish a grant program for health providers to provide 
telemedicine service for those in farming, forestry, and 
fishing industries. Another focus of the National Academies of 
Science report are cardio metabolic conditions. I will never 
forget last year the owner of an ambulance service telling me 
that his calls were way down.
    It wasn't due to the fact solely that there were fewer 
automobile accidents since people were not driving. It was that 
people who were experiencing symptoms of heart attacks were 
afraid to go to the hospital during COVID. And they should 
have. We also saw people putting off treatment and screenings 
that might have uncovered cancer at an earlier age. Here again, 
community interventions such as those where people can 
participate virtually like diabetes self-management training 
can help change the trajectory of life expectancy.
    As we continue to grapple with the delta variant and emerge 
from the pandemic, we should take stock in the areas where we 
have done well, like telehealth, as well as to analyze those 
areas that have worsen, like substance abuse disorders. So this 
hearing is very well timed, and I look forward to hearing from 
our panel. Thank you, Mr. Chairman.
    The Chairman. Well, thank you very much, Senator Collins. 
Senator Casey has to run so I am going to ask him if he would 
like to speak for a few minutes.
    Senator Casey. Mr. Chairman, thanks very much. I want to 
thank you and the Ranking Member for convening this hearing, 
and I will be brief. I start with an apology that I won't be 
able to stay for the entirety of the hearing. I will make sure 
that I and my staff review the testimony, the written testimony 
of Dr. Harris, Dr. Cooke, and Chief MacKenzie, and then submit 
questions for the record. But I want to thank you, Mr. Chairman 
and the Ranking Member for having this hearing. The documented 
decline in life expectancy for working age adults in our Nation 
and the socioeconomic disparities that are part of that trend 
are alarming, disturbing, and I think all of us--need to do 
something.
    Mr. Chairman, you were talking about in your opening 
remarks, the impact of stress and poverty on people having not 
just an adverse health impact, but literally being for some 
people, many people, a death sentence. That caught all of our 
attention, and the deaths of despair that you made reference to 
should call all of us to action. I know in Pennsylvania, we 
have a huge--still a huge challenge with substance use 
disorder.
    I have to say the Medicaid expansion in our state helped a 
lot, but the pandemic wiped out a lot of those gains. More than 
16 percent--the number of overdose deaths in our state 
increased, I should say, by 16 percent from 2019-2020, and that 
doesn't, of course, cover the whole impact of the pandemic. So 
I am grateful for this indulgence. I am grateful for this 
hearing. Thank you.
    The Chairman. Thank you very much, Senator Casey. And now 
we will get to our panelists who are with us virtually from 
around the country. And let me begin by introducing Dr. 
Kathleen Harris, who is a Professor of Sociology, Adjunct 
Professor of Public Policy and faculty fellow at the Carolina 
Population Center at the University of North Carolina.
    Dr. Harris's research focuses on social inequality and 
health, and she is the Chair of the Committee on Population at 
the National Academies of Sciences, Engineering and Medicine. 
Dr. Harris, thank you very much for being with us today.

   STATEMENT OF KATHLEEN MULLAN HARRIS, PH.D., JAMES E. HAAR 
   DISTINGUISHED PROFESSOR OF SOCIOLOGY, UNIVERSITY OF NORTH 
 CAROLINA, CHAIR, COMMITTEE ON RISING MIDLIFE MORTALITY RATES 
   AND SOCIOECONOMIC DISPARITIES, THE NATIONAL ACADEMIES OF 
      SCIENCES, ENGINEERING, AND MEDICINE, CHAPEL HILL, NC

    Ms. Harris. Good morning. Chairman Sanders, Ranking Member 
Collins and Members of the Subcommittee, thank you for the 
opportunity to testify today. My name is Kathleen Mullan 
Harris. I am the James Haar Distinguished Professor of 
Sociology at the University of North Carolina, Chapel Hill. And 
I am speaking to you today in my capacity as Chair of the 
National Academies Committee that produced the study, high and 
rising mortality rates among working age adults. As you just 
heard, our study was motivated by a huge problem.
    Between 2014 and 2017, life expectancy in the United States 
fell 3 years in a row, the longest sustained decline in a 
century. To make matters worse, this was not happening in our 
high income peer countries. So we wanted to understand why more 
Americans were dying in the prime of their lives, ages 25 to 
64, the most productive years and their parenting years. So we 
first set out to identify what causes of death were increasing 
and for whom. We examined trends from 1990 to 2017 and 
identified three main drivers of rising mortality, deaths due 
to drug poisoning and alcohol induced causes, suicide, and 
cardiometabolic diseases like hypertension, diabetes, stroke, 
and heart disease.
    Rising death rates first occurred among younger white women 
and men, those aged 25 to 44, living outside of large cities, 
but then spread to most racial and ethnic groups and geographic 
areas of the country. Although rising death rates began among 
whites, Blacks consistently experienced much higher mortality. 
Those with less education and income always experienced higher 
death rates, and this disadvantage was widening among whites. 
Geographic disparities also widen between large urban areas and 
less populated rural areas, where death rates were increasing 
more rapidly, especially in Appalachia, New England, the 
industrial Midwest, and parts of the Southwest and Mountain 
West.
    What was happening? We then searched for explanations 
through an extensive review of the existing research 
literature. Drug and alcohol related deaths were the most 
important contributor. Explanations involve supply side factors 
like weak Government, Governmental oversight, and actions by 
the pharmaceutical industry, pain control advocacy groups, and 
physician prescribing. Demand-side factors included increasing 
prevalence of physical pain, declining psychological health, 
and long term trends of economic adversity that affected adults 
with less than a college education and geographic areas where 
manufacturing and mining jobs had disappeared.
    Suicide rates increased primarily among whites, especially 
white men, and in less populated rural areas. Economic factors 
are important. Economic downturns, low wages, increasing 
foreclosure rates and a weak safety net increase suicide rates. 
Cardiometabolic diseases also played a significant role, a 
complex role. Up until 2010, science was saving us. Medical 
interventions and public health campaigns to reduce smoking 
drastically cut down cardiovascular death rates. But these 
declines hit the mountain tsunami of the obesity epidemic, 
which was fueling alarming increases in hypertension, diabetes, 
stroke, and heart disease.
    By 2010, the lagged effects of obesity overwhelmed what 
medicine could do to save lives. So you can see there is no one 
cause that explains the increase in death rates, but we noted 
three common factors underlying all the trends economic 
adversity, two, economic inequality, and volatility. Every one 
of these trends and the themes underlying them are being 
magnified by the COVID 19 pandemic. This is a crisis in America 
that existed before COVID, and it will continue after COVID.
    Our life expectancy is declining relative to our peers 
despite our wealth. Solutions need to be multifaceted. The 
committee made several recommendations. We need policies that 
can be implemented for those agencies and stakeholders closest 
to the addiction crisis to improve regulation and oversight and 
modify practices just for the prevention and the treatment of 
substance use disorders. Economic policies are needed to 
address the economic and social strains that make communities 
vulnerable to opioids and other drugs. Obesity prevention 
programs need to start early in life before obesity and focus 
on the most vulnerable, often the low income populations.
    We need to balance the right of the food industry and 
public health imperatives to reduce food and beverages that 
contribute to obesity. Death rates are lower in states that 
have expanded Medicaid under the Affordable Care Act. The 12 
states that have not yet expanded access to Medicaid should do 
so as soon as possible.
    All studies of mortality report on the stark disadvantage 
and life expectancy among racial and ethnic minorities in the 
United States. Reducing this racial gap will significantly help 
to improve our global standing in life expectancy and catch up 
to our other rich nations.
    Thank you for the invitation to testify and I welcome any 
questions you have.

    [The prepared statement of Ms. Harris follows:]
              prepared statement of kathleen mullan harris

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    The Chairman. Dr. Harris, thank you very, very much. I 
believe that Senator Braun is going to introduce Dr. Cooke.
    Senator.
    Senator Braun. Thank you, Mr. Chairman and Ranking Member 
Collins. My pleasure to introduce Dr. William Cooke, fellow 
Hoosier. Graduated with honors from the IU School of Medicine 
in 2001. Completed his family medicine residency at Memorial 
Hospital in Muncie, Indiana. Dr. Cooke is a fellow of the 
American Academy of Family Medicine and the American Society of 
Addiction Medicine, specializing in addiction and HIV medicine. 
He has received national recognition for quality and 
compassionate care, including being named Family Physician of 
the Year by the American Academy of Family Physicians.
    Dr. Cooke lives in his hometown of New Albany with his wife 
Melissa and their six kids. He also serves as the Executive 
Director of a nonprofit Refresh, the hospital's Medical 
Director at the Critical Access Hospital in Scott County, and 
Co-Director of the Rural Center of HIV and STD Prevention. In 
2015, Austin, Indiana became the epicenter of the national 
opioid crisis and the worst drug fueled HIV outbreak in U.S. 
history. At the time, Dr. Cooke was the only physician in this 
rural Southern Indiana town.
    In response, he and his team went the extra mile to improve 
their own capacity to care for people living with HIV, even 
going door to door in his community to provide care for the 
people newly diagnosed. Today, almost 80 percent of Dr. Cooke's 
patients living with HIV have undetectable viral loads. Dr. 
Cooke continues to provide full spectrum primary care to those 
in his community, including the people with substance abuse 
disorders and mental health challenges. Look forward to hearing 
your testimony today.
    The Chairman. Dr. Cooke.

  STATEMENT OF WILLIAM E. COOKE, M.D., FAAFP, FASAM, AAHIVS, 
   OWNER AND MEDICAL DIRECTOR, FOUNDATIONS FAMILY MEDICINE, 
                           AUSTIN, IN

    Dr. Cooke. [continuing]. Just a few seconds to thank 
Senator Braun and the other panelists, Sheriff MacKenzie and 
Dr. Harris presenting today. Good morning, Chairman Sanders, 
Ranking Member Collins and other Members of the Subcommittee. I 
spent the last two decades working to increase health equity in 
underserved areas of Southern Indiana. That is where I grew up, 
surrounded by poverty, toxic stress, and substance use. And 
those factors actually contributed to my grandpa's death in his 
50's, my aunt's overdose death at the age of 39. Although my 
parents escaped that fate, providing my brother and me greater 
opportunity, our family remains an example of how early death 
profoundly affects life expectancy.
    During medical school, I was impressed by our Nation's 
investment in research and technology. There is no place on 
earth better keeping sick people alive. After graduating as a 
family physician, I felt prepared to care for the entire 
community at my health clinic, regardless of the age or 
condition, at our critical access hospital, delivered babies, 
worked in the emergency department, and treated critically ill 
patients. Even so, nothing could have prepared me for the 
suffering I found in the Nation's heartland.
    Young people with late stage diabetic complications, women 
dying of cervical cancer, and a man with a tumor on his tongue 
so large he couldn't even close his mouth. These encounters 
made me realize that we focus so heavily on treating sick 
people that we forgot to promote healthy people. As the Surgeon 
General's report on community health and economic prosperity 
indicates, our Nation is at a health disadvantage due to 
inequitable access to vital community conditions that shape 
health and well-being, such as clean air and water, nutritious 
food, safe housing, reliable transportation, a livable wage, 
and a sense of belonging and civic power. There are far too 
many people like my patients who lack these vital conditions.
    Children don't choose where they are born or where they are 
raised, and if they were born into these low opportunity 
neighborhoods, their life chances are diminished all the same. 
Life was more comfortable before I recognized these inequities. 
My discomfort caused me to cling to beliefs that I had been 
taught about people who were different than me. But close 
encounters with real people convinced me that health and 
prosperity are not solely dependent on comfort or choice but 
are often limited by access to resources and opportunity. After 
all, people could only make choices from the options available 
to them.
    The greater the inequality, the greater the inequity, the 
greater the burden of disease, disability, and early death. We 
must move beyond the path of disease oriented model and do no 
harm, to a proactive person centered model of protect from 
harm. And primary care physicians are uniquely positioned to do 
just that. Research confirms access to primary care improves 
health outcomes and life expectancy. Now, you have heard a lot 
of bad news from the report. Let me just share some hopeful 
progress we have made in Indiana. As Senator Braun mentioned, 
my community experienced the worst drug fueled HIV outbreak in 
U.S. history in 2015. But things look a lot different today, 
despite having the highest percentage of people who inject 
drugs living with HIV in the state.
    We have defied conventional wisdom by being able to boast 
the best viral suppression rate in the state. We went from 
nearly 200 new cases a year to only 1 last year. And although 
Indiana leads the country in hepatitis C cases, we have cut our 
community cases by over 75 percent. We have also seen an 
explosion of people with substance use disorders entering into 
treatment and recovery, along with fewer diabetic 
complications, better pain management without the use of 
opioids, improved prenatal care, fewer hospitalizations, and 
the list could go on.
    We did this with very limited resources, and I believe we 
have reduced the impact of social determinants on our community 
by getting outside the four walls of my clinic and getting into 
where people live and experience harms. A few examples include 
school, jail, and mobile clinics working with the sheriff and 
the recovery community to respond to overdoses and people in 
crisis by providing them direct access to treatment. Project 
Echo enables my team to provide interdisciplinary access to 
endocrinology, rheumatology, infectious disease, addiction 
medicine, and women's health.
    Telehealth allows patients greater access to us and to 
their support networks. And interdisciplinary teams with 
diverse lived experiences help my patients feel safe accessing 
care and overcoming barriers. Integrating health care with 
Centerstone, a nonprofit behavioral health system, allows for 
decreased stigma and barriers to mental health. Community 
recovery and faith based partners help meet basic human needs 
for food, safety, and belonging.
    Now our fee for service system doesn't reimburse for these 
interventions, which highlights the need to move toward a 
payment model designed to address health inequities. Health 
care disasters don't just happen, they develop right before our 
eyes, unseen or ignored before it is too late, then the people 
who are already suffering are the ones who are harmed the most. 
We must recognize the cumulative effect of every person's 
health on our Nation's health.
    By taking this crisis of health inequity and declining life 
expectancy on now, we can reestablish the United States as the 
healthiest place in the world to live. Thank you for the 
opportunity to discuss this important topic with the Committee, 
and I look forward to your questions.

    [The prepared statement of Dr. Cooke follows:]
                 prepared statement of william e. cooke
    Good morning, Chairman Sanders, Ranking Member Collins, and Members 
of the Subcommittee: I am Dr. William Cooke, a family physician from 
Indiana. Thank you for the opportunity to speak to you today.

    I've spent two decades working to increase health equity in 
underserved areas of Southern Indiana. That's where I grew up 
surrounded by poverty, toxic stress, and substance use. Those factors 
contributed to my grandpa's death in his fifties and my aunt's overdose 
death at 39. Although my parents escaped that fate, providing my 
brother and me greater opportunity, our family remains an example of 
how early deaths profoundly affects life expectancy.

    During medical school I was impressed by the investment we've made 
in research and technology. There's no place on earth better at keeping 
sick people alive.

    As a family physician I felt prepared to care for the entire 
community at my office, regardless of age or condition. At our critical 
access hospital, I delivered babies, worked in the Emergency 
Department, and treated critically ill patients.

    Even so, nothing could have prepared me for the suffering I found 
in the Nation's heartland. Young people with late-stage diabetic 
complications, women dying from cervical cancer, and a man with a tumor 
on his tongue so large he couldn't close his mouth. These encounters 
made me realize that our healthcare system focuses so heavily on 
treating sick people it fails to promote healthy people. As the Surgeon 
General's report on Community Health and Economic Prosperity indicates, 
our Nation is at a health disadvantage due to inequitable access to 
vital community conditions that shape health and well-being, such as: 
clean air and water, nutritious food, having safe housing, reliable 
transportation, a livable wage, and a sense of belonging and civic 
power. \1\
---------------------------------------------------------------------------
    \1\  Community Health and Economic Prosperity: Engaging Businesses 
as Stewards and Stakeholders--A Report of the Surgeon General, 
(Atlanta: US Department of Health and Human Services, Centers for 
Disease Control and Prevention, and Prevention Office of the Associate 
Director for Policy and Strategy, January 2021), 11, https://
www.hhs.gov/sites/default/files/chep-sgr-full-report.pdf.

    There are far too many people, like many of my patients, who lack 
these vital conditions. Children don't choose to be born and raised in 
these ``low opportunity neighborhoods,'' yet their life chances are 
---------------------------------------------------------------------------
diminished all the same.

    Life was more comfortable before I recognized these inequities. My 
discomfort caused me to cling to beliefs I'd been taught about people 
who were different from me. But close encounters with real people have 
taught me that health and prosperity are not solely dependent on effort 
and choice but are often limited by the resources and opportunities 
available where they live. After all, people can only make choices from 
the options available to them.

    The greater the inequity the greater the burden of disease, 
disability, and early death. We must move beyond the passive, disease-
oriented model of ``do no harm'' to a proactive, person-centered model 
of ``protect from harm.'' Primary care physicians are uniquely 
positioned to do just that. Research confirms access to primary care 
improves health outcomes \2\ and life expectancy. \3\
---------------------------------------------------------------------------
    \2\  Starfield B, Shi L, Macinko J. Contribution of primary care to 
health systems and health. Milbank Q. 2005;83(3):457-502. doi:10.1111/
j.1468-0009.2005.00409.x.
    \3\  Basu S, Berkowitz SA, Phillips RL, Bitton A, Landon BE, 
Phillips RS. Association of Primary Care Physician Supply With 
Population Mortality in the United States, 2005-2015. JAMA Intern Med. 
2019;179(4):506-514. doi:10.1001/jamainternmed.2018.7624.

    You've heard a lot of bad news. I'd like to highlight some hopeful 
---------------------------------------------------------------------------
progress we've made in Indiana.

    My community experienced the worst drug fueled HIV outbreak in U.S. 
history in 2015, but things look different today. Despite having the 
highest percentage of people who inject drugs living with HIV in the 
state, we have defied conventional wisdom by boasting the best viral 
suppression rate in the state. We went from nearly 200 new cases of HIV 
in 2015 to only having one last year. Although Indiana leads the 
country in hepatitis C cases, we've decreased our cases by over 75 
percent. We've also seen an explosion of people with substance use 
disorder enter treatment and recovery, along with fewer diabetic 
complications, better pain management without the use of opioids, 
improved prenatal care, reduced hospital admissions, and the list goes 
on. We did this with no specialists and limited resources. I believe 
we've reduced the impact of social determinants on our community by 
getting outside of the four walls of my clinic. A few examples include:

          Mobile, school, and jail based clinics.

          Working with our sheriff and recovery community to 
        respond to overdoses and people in crisis by providing them 
        direct access to treatment.

          Project ECHO enables my team to provide 
        interdisciplinary access to endocrinology, rheumatology, 
        infectious disease, addiction medicine, and women's health.

          Telehealth allows patients greater access to us and 
        their support networks.

          Interdisciplinary teams with diverse lived 
        experiences help patients feel safe accessing care and 
        overcoming barriers.

          Integrating care with Centerstone, a nonprofit 
        behavioral health system.

          Community, recovery, and faith-based partners help 
        meet basic human needs for food, safety, and belonging.

    Our fee for service system doesn't reimburse for these 
interventions, which highlights the need to move toward payment models 
designed to address health inequities.

    Healthcare disasters don't just happen; they develop right before 
our eyes, unseen or ignored until it is too late. \4\ Then, the people 
who were already suffering are the ones who are harmed most. We must 
recognize that there is a cumulative effect of every person's health on 
our Nation's health. But by taking on this crisis of health inequities 
and declining life expectancy now, we can reestablish the United States 
as the healthiest place in the world to live.
---------------------------------------------------------------------------
    \4\  Cooke, W. 2021.Canary in the Coal Mine: A Forgotten Rural 
Community, a Hidden Epidemic, and a Lone Doctor Battle for the Life, 
Health, and Soul of the People. Tyndale House Publishers.

    Thank you for the opportunity to discuss this important topic with 
the Committee and I look forward to your questions.
                                 ______
                                 
    The Chairman. Well, Dr. Cooke, thank you for testifying and 
congratulations on your work.
    Senator Collins is going to introduce Police Chief 
Mackenzie.
    Senator Collins. Thank you very much, Mr. Chairman. I am 
delighted to introduce Kennebunk Police Chief Robert Mackenzie. 
He is 33rd--a 33 year veteran of law enforcement. The Chief 
recently received the Outstanding Contribution to Law 
Enforcement Award from the main Chiefs of Police Association 
for his incredible work in the field of substance abuse 
disorder in 2020.
    This was certainly a well-deserved honor and recognition 
from his peers. Chief Mackenzie is a graduate of the FBI 
National Academy in Quantico, Virginia, and he holds a Bachelor 
of Science degree in criminal justice from Husson University. 
He is a true leader in this area and I am delighted he is 
joining us today. Thank you.
    The Chairman. Chief.

 STATEMENT OF ROBERT F. MACKENZIE, CHIEF OF POLICE, KENNEBUNK 
                POLICE DEPARTMENT, KENNEBUNK, ME

    Mr. MacKenzie. Thank you, Chairman Sanders and Ranking 
Member Collins, and Members of the HELP Committee. So I am Bob 
Mackenzie, a Police Chief for 13 years in the town of 
Kennebunk. But I have been in law enforcement for over 33 years 
and actually in public safety since I was 14 years of age, as a 
firefighter and then as an EMT from 16 years of age.
    I am also a Rotarian, past President of Kennebunk Rotary 
Club. I also Chair the Rotary District 7780 Recovery 
Initiative. I also serve on the Board of Directors from 
Milestone Recovery in Portland, Maine and United Way of 
Southern Maine. So I witnessed far too many times the tragedies 
due to the opioid epidemic and disease of substance use 
disorder, otherwise known as SUD. Now as devastating as these 
losses are, it became even more real for me when I realized my 
daughter was suffering from an opioid use disorder. Now, 
because of my work on an SUD that specialized in the opioid 
epidemic, I knew my daughter was at great risk for death.
    I was fortunate to have the resources and know how in order 
to help my daughter find her path to sobriety, and I am proud 
to say she is more than 18 months in recovery now. I also know 
that there are many loved ones not as fortunate as mine and 
2020 certainly proved to be a devastating year, and not only 
because of COVID, but because of the loss of lives to SUD and 
the opioid epidemic. The most recent national statistics I have 
seen for 2020, as Senator Collins said, was a 30 percent 
increase over 2019, but that equates to about 93,000 Americans 
that died. And what is important to remember is that these 
stats are somebody's loved ones. Now, on a positive note, 
resources for SUD have and will continue to adjust for the 
pandemic and we are becoming very creative as to our approach.
    We have implemented a number of initiatives in our region 
over the past 5 years and I will share three of them that I 
believe are most relevant for this discussion. The first thing 
we needed to do is reduce stigma, because stigma is the No. 1 
barrier for those that suffer from SUD to enter recovery. 
Stigma related to SUD is far too prevalent in our society. But 
once people are educated, they tend to open their minds and 
their hearts.
    I began educating our Kennebunk Rotarians on SUD and the 
opioid epidemic and trained them on how to use naloxone, which 
is the drug that reverses an opioid epidemic--overdose, that 
is. I went on to train our Chamber of Commerce, our businesses, 
held several community forums, and even students at Kennebunk 
High School. I have trained at least 35 Rotary Clubs throughout 
Maine and New Hampshire, all with the goal of raising awareness 
and reducing stigma. Now, another initiative that is currently 
underway in our community is called Kennebunk Area Response to 
Substance Use Disorder.
    This is where we convene stakeholders of three towns to 
include our town managers, law enforcement positions, recovery 
centers, faith based leaders, mental health providers, those in 
recovery and more. We first identify the issues surrounding 
SUD, what resources we currently have, but even more important, 
we identify gaps so we can create a strategic plan to close 
those gaps. This type of initiative educates everyone and so we 
are all on the same page, we are more efficient, cost 
effective, and we are not working in silos any longer.
    The third initiative in the Kennebunk area includes a 
community based fundraising group called Above Board that came 
forward with a desire to raise money to support our efforts on 
saving lives. A total of $110,000 was raised and was utilized 
to train community members to become recovery coaches. A 
recovery coach is a mentor to those with SUD and helps them 
find a path to recovery and stay in recovery. In addition, 
these funds were used to train our law enforcement officers on 
how to help those with SUD.
    Now there are times when law enforcement needs to use 
enforcement, but there are many more times when law enforcement 
officers can be an ally and help those in need. I am proud to 
say that this model of law enforcement training became a 
mandatory training module for all of our officers in the State 
of Maine last year. These are only a few of the initiatives we 
have undertaken in our region. Our community is dedicated to 
helping those with SUD because we know recovery is possible. I 
have seen it through my own family, and even more so at work 
with those struggling with SUD were at great risk of death, but 
are now healthy, happy, and productive citizens who are doing 
great work to strengthen the recovery community.
    The key word here is community. It is by working together 
at the local level where we know our community is the best and 
have the ability to utilize the resources of the state and 
Federal Governments, we will make a difference and save lives. 
I thank you for your time and attention to this matter and 
welcome any questions that you may have.

    [The prepared statement of Mr. MacKenzie follows:]
               prepared statement of robert f. mackenzie
    Thank you Chairman Sanders, Ranking Member Collins and Members of 
the H.E.L.P. Committee. My name is Bob MacKenzie and I am the Chief of 
Police in Kennebunk, Maine. I am a veteran of public safety for over 40 
years, to include 33 years in law enforcement, serving as Chief for the 
past 13 years, and also served as a firefighter/Emergency Medical 
Technician up to the Critical Care level for over 30 years. I am also a 
proud Rotarian, Past-President of the Kennebunk Rotary Club and 
Chairman of the Rotary District 7780 Recovery Initiative. I also serve 
on the Board of Directors for Milestone Recovery and am a board member 
of United Way of Southern Maine.

    I appreciate the opportunity and am honored to testify before you 
on a subject near and dear to my heart, the Opioid Epidemic and 
Substance Use Disorder and how it has impacted our society through not 
only the lens of a devoted public servant, but as a father.

    Through my decades of public safety, I have been a firsthand 
witness to the death and destruction caused by the disease of substance 
use disorder, (SUD) and the Opioid Epidemic far too many times. I have 
seen families devasted by the loss of their sons/daughters, bothers/
sisters, mothers/fathers, and so on.

    As devastating as these losses are it became even more real for me 
when I realized my daughter was suffering from an opioid use disorder. 
Because of the work I have been doing on SUD, specializing in the 
opioid epidemic, I knew my daughter was at great risk for death and I 
was afraid I would be on the receiving end of a death notification. I 
was fortunate to have the resources and know-how in order to help my 
daughter find sobriety. It wasn't easy for her as she experienced a 
reoccurrence, but I am proud to say she is now 18 months in recovery 
and working with me on an initiative to help others with SUD.

    There are many families and loved ones not as fortunate as ours and 
2020 was a devastating year, not only because of COVID, but because of 
the loss of lives to SUD and the Opioid Epidemic. Maine saw a 33 
percent increase in overdose deaths in 2020, losing 504 lives to 
overdose. The most recent national statistics I have seen shows a 
similar 30 percent increase, estimated to have a death toll of 93,000 
Americans compared to over 72,000 deaths in 2019. What's important to 
remember, is these statistics are somebody's son/daughter, brother/
sister, mother/father, etc. . . . My heart goes out to each and every 
one of them.

    There have been resources allocated to SUD and the opioid epidemic, 
so you may ask why are we failing? We had made progress pre-pandemic, 
but SUD is a disease of isolation. COVID forced all of us to isolate 
and many of the resources that had been made available for those 
suffering with SUD were no longer available or took much time to adjust 
and could only be utilized remotely. Many of those with SUD do not have 
the resources to utilize online services. It is typical for those that 
use to use in solitude, and many die alone after using opioids.

    On a positive note, resources for SUD have and will continue to 
adjust for the pandemic and we are becoming creative as to our 
approach. We have implemented a number of initiatives in our region 
over the past 5 years.

    An example I will use is what we have done in Kennebunk, ME. The 
first thing I knew we needed to do was reduce stigma as stigma is the 
#1 barrier to recovery for those that use. Stigma related to SUD is far 
too prevalent in our society. Many believe those that use substances 
are less than and have little value in society. Once educated, people 
tend to open their minds and their hearts, thus progress can be made.

    I first educated Kennebunk Rotarians on SUD and the opioid epidemic 
and trained many how to use Naloxone, the drug that reverses an opioid 
overdose. Once that was completed I trained our Chamber of Commerce, 
businesses, community members through various forums, Adult ED and even 
students at Kennebunk High school. Then our Rotary District became 
involved and I trained at least 35 Rotary clubs, presented at our 
Rotary District conference where I was fortunate enough to educate over 
100 Rotarians from three Rotary Districts, and have traveled throughout 
Maine, New Hampshire Connecticut and upstate New York. Rotary Clubs in 
seacoast New Hampshire have held community forums on SUD and the Opioid 
Epidemic. All with the goals of reducing stigma and saving lives.

    A new initiative our Rotary District has embraced and is 
financially supporting is the training of 30 Master Trainers with the 
goal of educating communities throughout our region on Adverse 
Childhood Experience's, otherwise known as, (ACE's). ACE's has proven 
to have significant negative outcomes on physical, mental and 
behavioral health, to include SUD for individuals and communities. 
These master trainers are now training school officials, law 
enforcement, community members and more to identify and work with at 
risk youth in a trauma-informed way. Approaching problems in a 
constructive, understanding way, called trauma informed care, rather 
than traditional punitive methods, has a substantial positive impact on 
future levels of addition, crime, violence and other societal issues.

    A third initiative in the Kennebunk area includes a community-
based, fund-raising group called Above Board that came forward with the 
desire to raise money to support our efforts on savings lives in 2018 & 
2019. A total of $110,000.00 was raised and was used to train community 
members to become Recovery Coaches. A Recovery Coach is a mentor to 
those with SUD and helps them find their path to recovery, and stay in 
recovery. In addition, these funds were used to train our law 
enforcement officers on how to help those with SUD. There are times 
when law enforcement needs to use enforcement, but there are many more 
times when law enforcement officers can be an ally and help those in 
need. I am proud to say that this model of law enforcement training 
became a mandatory training module for all officers in Maine last year. 
We also were able to utilize these funds to partner with a mental 
health agency as so a clinician would ride-along with officers and 
assist those with SUD and mental health issues.

    The fourth initiative currently underway in our community is the 
Kennebunk Area Response to SUD. We convened stakeholders of three towns 
to include, town managers, law enforcement, physicians, recovery 
centers, faith based leaders, mental health providers, those in 
recovery and more. We first identified the issues surrounding SUD, what 
resources we currently have but even more important, identified gaps as 
so we can create a strategic plan to close the gaps. This type of 
initiative educates everyone as so we are on the same page, are more 
efficient, cost effective and not working in silos.

    The fifth initiative we have utilized in Kennebunk are interns. In 
early 2020 we partnered with the University of New England to bring on 
an intern from UNE's School of Social Work where we had a graduate 
student intern at Kennebunk PD for a full semester. This student was 
supervised by a licensed clinician, but was able to conduct ride-along 
with officers as well as conduct follow-ups on those who were 
struggling with SUD and mental health issues. Given the success of this 
initiative, we are currently in a process to hire a mental health 
clinician. We also utilized AmeriCorps to have a VISTA intern at our PD 
for 2 years to provide additional support for our efforts on SUD.

    A sixth initiative prior to the pandemic was partnering with The 
Family Restored, which is a support group for families of loved ones 
struggling with SUD. Family is a support network and can play a 
critical role of a loved ones recovery. I had many sleepless nights 
when my daughter was struggling, and I had a pretty decent handle on 
resources and what needed to be done. Most families are at a loss, 
don't know what to do or where to turn and in many instances 
unknowingly enable their loved ones. Family support groups is a harm 
reduction tool and should be prevalent and accessible throughout our 
country.

    Even with the initiatives we have brought forth there are many 
other initiatives which would be very beneficial and I feel are needed 
in order to have the best outcomes and save lives. Here are some of my 
thoughts:

    Peer led recovery community centers, such as the Portland Recovery 
Community Center, (PRCC) is a community center open to those in need. 
PRCC's vision statement explains it well:

        PRCC's vision is that every person affected by addiction in 
        Maine will have direct access to a local recovery community 
        center that provides support groups, education, and individual 
        resources to enhance their ability to heal, strengthen and grow 
        in their recovery pathway, throughout all stages of their 
        journey.

    Maine currently has 13 recovery community centers with the goal of 
17, one for each county in Maine. I believe once again we need one in 
every community in our Nation as SUD is that prevalent.

    Another vital need is recovery/detox centers. I can speak as a 
board member of Milestone Recovery in Portland, Maine which is a non-
profit center providing a life-saving function to those with SUD from 
all over. Milestone runs on a very tight budget but does not refuse 
anyone who cannot pay. In Maine there are very few options for recovery 
centers, and many of the ones we do have are for-profit. Many with SUD 
do not have the means to pay or have health insurance that cover the 
costs, so there are many times where people in need do not receive the 
help they want/need. It is important to note that many of those with 
SUD who are ready for recovery only have a short window to get help 
before their disease changes their mind.

    It is my opinion that mental health clinicians should be available 
to every law enforcement agency. Based on our experience with our 
intern and clinician, and based upon my over 33 years on the job, we 
need the expertise of a licensed professional clinician to assist us, 
not only at the time of mental health events, but to conduct follow-up 
with those suffering from SUD/mental health calls that law enforcement 
come into contact with. Clinicians have the know-how, time and ability 
to connect those in need to the correct services. Although law 
enforcement officers are not licensed mental health clinicians, we 
routinely have to play that role as options are limited to those in 
need. Our agency and town has benefited from the COPS hiring grants in 
the past, but now is the time to allocate funds for licensed clinicians 
to be embedded within law enforcement agencies. It's not only a 
community policing initiative, it will save lives and save money in the 
long run.

    Thank you once again for this opportunity and I appreciate your 
time to this critical issue facing our country. By working together we 
will make a difference and save lives!
                                 ______
                                 
    The Chairman. Chief, thank you very much. Let me begin the 
questioning with Dr. Harris. Dr. Harris not only are we seeing 
a decline in life expectancy in many parts, many sectors of our 
society, but we have for many years lagged behind other 
wealthy, industrialized countries.
    What impact would it have on life expectancy in America if 
all of our workers had decent wages, that was at least a 
livable wage, decent housing, and if we did what every other 
major country on earth does and provide health care as a human 
right? Would that, in your judgment, impact life expectancy in 
the country?
    Ms. Harris. Yes, it would. A lot of people look at the 
differences in life expectancy between the United States and 
our peer countries and, attributed it to the racial and ethnic 
disparity. But even if we eliminated that, we would still be 
behind. So the cause is much deeper and broader, and it is 
rooted in inequality, socioeconomic inequality, poor economic 
conditions, and the stress of living with those conditions.
    I think that opportunities for jobs, if everybody had a job 
that would provide them with a sense of meaning and dignity and 
purpose in life, and it would allow them to take care of their 
families or promote their children or upward mobility. And I 
think that would really cut to the heart of helping us catch up 
to other rich nations in life expectancy.
    The Chairman. Thank you very much. Let me ask Dr. Cooke a 
question, and congratulations, Doctor, for the work that you 
are doing taking health care out of the clinic, into the 
community. Talk a little bit about, if you might, the 
physiology of poverty. What happens to somebody who is 
struggling economically, who maybe has given up hope for 
himself or herself, the kids? How does that impact their 
outlook on life and their tendency to use drugs, alcohol, 
suicide, self-destructive behavior?
    Dr. Cooke. Yes. Oftentimes when I am working with people, I 
realize that they have made a lot of effort in their life to 
get to where they wanted to be in life. But somewhere along the 
way, circumstances had appeared to be so overwhelming that they 
developed this sense of learned helplessness. No matter what 
they do, they can't get ahead. And one of the things that I 
found is the most helpful when I am working with people is 
trying to reestablish within them the sense of purpose and 
meaning.
    When they find that and they are able to project that into 
the world, all of a sudden some of those circumstances don't 
seem as overwhelming any longer. And when we look at substance 
use disorder, the recovery community is such a vital piece of 
that. But toxic stress is damaging to the body. It is damaging 
to the mind, the brain the way it is developed with childhood--
adverse childhood experiences. It disrupts the neural 
development, and it leads to these behaviors that then lead to 
poor health outcomes, unfortunately.
    The Chairman. Thank you. Chief MacKenzie, as a Police 
Chief, you and your department are on the front lines every day 
dealing with these things, in your personal judgment, what are 
the causes today that bring young people especially to a 
dependency on drugs or alcohol? What is going on?
    Mr. MacKenzie. Certainly. Well, I agree with regard to the 
issue around adverse childhood experiences. A lot of research 
has been--the scientific research has been done on that. So 
children that grow up with adverse experiences in their home 
are much more likely to have issues anywhere from suicide 
health issues, but also substance use disorder.
    Any child that grows up in that type of environment, they 
could be subject to substance abuse in their home, separation 
or divorce of their parents, mental illness, domestic violence, 
neglect, both emotional, physical, or sexual abuse. But the 
more issues that they have, the more chances are that their 
life expectancy is going to be shorter.
    I know there was a Florida study of juvenile offenders who 
have 50 percent of them had an ACE score of four or more. And 
to put that in perspective, those with ACE scores of 4 or more 
were 12 times more likely to have attempted suicide, 7 times 
more likely to be an alcoholic, or 10 times more likely to have 
injected street drugs, and ACE scores of 6 or higher, an almost 
20 years short end of lifespan. So I definitely feel that ACE 
has a lot to do with it.
    The Chairman. Well, thank you very much, Chief.
    Senator Collins.
    Senator Collins. Thank you, Mr. Chairman. Let me begin my 
questions by first thanking Chief Mackenzie and Dr. Cooke for 
so eloquently sharing with the Committee your own family's 
struggles. It certainly puts a human face on the statistics, 
and it reminds each and every one of us, if we don't already 
know it, that no family is immune. And I think that is a really 
important lesson.
    Thank you for your willingness to share your own personal 
stories. Chief, I want to start with you. Prior to the start of 
the COVID pandemic, we started to see some glimmers of progress 
in the State of Maine. I remember in 2018 and 2019, the number 
of deaths, while still unacceptably high, was going in the 
right direction. It was declining.
    Then Congress had passed a lot of legislation to help, 
including a bill that I co-authored related to opioid peer to 
peer support networks and safe disposal of unused medications, 
and Congress also significantly ramped up the funding that we 
provided. And yet once the pandemic hit, we seemed to lose all 
of the progress that we made.
    Indeed, as both you and I mentioned, Maine experienced a 
record number of losses, 504 deaths last year, which was a 33 
percent increase over the year before. What happened? What 
factors do you think caused us to lose the ground that we were 
gaining?
    Mr. MacKenzie. Certainly. So, once COVID came--once COVID 
came, what we were told to do is isolate. Now, substance use 
disorder is a disease of isolation. Many people that use, use 
in solitude, they are by themselves when they use in many 
instances. Now, in addition, many, many of the resources that 
have become available were really no longer available, 
especially the peer to peer support, the in meeting--the in-
person meetings that were being held.
    Now we tried to struggle through that and be creative and 
maybe do some meetings via zoom and other platforms. But one of 
the issues is that many people that utilize substances do not 
have the resources or the ability to go online. It is not just 
that easy for them. So COVID certainly just forced the issue of 
isolation more. And I believe that is why we have seen such an 
issue with the deaths increasing.
    Senator Collins. Thank you. Dr. Cooke, in the Chief's 
testimony he referred to the stigma of getting assistance. I 
believe it was the Chief that mentioned that. And I have seen 
that time and time again in talking with friends who are 
struggling or have children who are struggling. I have also 
seen a success story in this regard, and that is at the V.A.. 
The Veterans Administration has been using telemedicine to 
reach out to veterans in rural areas who are struggling with 
substance abuse disorders or other behavioral health 
challenges.
    What they have found is their no-show rate has dropped 
dramatically and that the veterans got much more comfortable 
with telemedicine counseling and treatment sessions than they 
did being seen going into a counselor's office. Now, that said, 
that there is that stigma. But I wanted you to comment, you 
alluded to the fact that we need to revise our reimbursement 
policies because we temporarily are reversing--or reimbursing 
while COVID is going on, but I fear that is going to come to an 
end. How important is telemedicine in reaching people and how 
important is that reimbursement?
    Dr. Cooke. Thank you for that question. We told everybody 
to socially isolate, right, socially distance from each other, 
and I think what we meant by that was physically distant from 
other people. We really needed to maintain our social 
connections with other people. And telemedicine is a wonderful 
tool to be able to do that. It doesn't replace in-person 
meetings. It doesn't replace face to face interactions with 
people, but it does allow us to stay connected to people that 
we would otherwise be physically distant from.
    By--if you look at the Ryan White program, there is a 
reason why the viral suppression rate of people living with HIV 
in the Ryan White program is better than in other clinics. And 
that is because they address those underlying critical, vital 
community conditions, those social determinants of health, that 
social health and equity of transportation and such. By 
allowing those Ryan White funded clinics access to money that 
can provide transportation, that can provide social 
interactions, and support groups.
    We just recently developed a statewide support group for 
people living with HIV so they know they are not alone, and we 
can get through this together. So I think looking at a unique 
ways to reimburse, better ways to stay connected with people to 
support them having those access to vital community conditions, 
would help support healthy people and not just continue to 
focus on the disease model.
    Senator Collins. Thank you.
    The Chairman. Thank you, Senator Collins.
    Senator Murphy.
    Senator Murphy. Thank you very much, Mr. Chairman. Thank 
you, Senator Collins, for convening this really important 
hearing. Thank you to the three of you for the great work you 
do in this field. I appreciate the focus that we have already 
heard today on the social determinants of health. You have all 
covered it in one way or the other. Senator Sullivan of Alaska 
and I have introduced legislation that would set up a series of 
grants to communities to better integrate health care services 
and social services. Dr. Cooke, I wanted to--because you have 
raised this in a couple of different ways in testimony and 
answers to questions.
    I wanted to ask you your advice on how to structure the 
kind of programing necessary to link together social services, 
whether it be nutritional services, housing services, job 
training services, and health care services. Is that better off 
housed on the social service side, better off housed on the 
health care side, better off done by third parties that are 
bringing everybody together in one communal table? Have you 
found any way that this works better?
    Dr. Cooke. I would say all the above. Students from Yale 
just recently published a report on public health funding, and 
that is one of the things that they looked at, is kind of 
thinking outside the box and not just funding health 
departments and nonprofit health centers, but actually funding 
the entire community through coalitions. And I think it takes 
the community all working together across the sectors to really 
address those underlying social determinants of health.
    There is a model called ROSC, Recovery Oriented Systems of 
Care, and it looks at the unique factors within each unique 
community, because every community is different, it looks 
different, and needs--has different needs. And it allows that 
community to figure out what is keeping people down. What is 
keeping people from being healthy and well and having purpose 
and meaning in their life.
    Allows the cross-sector coalition to develop strategies and 
definitions that the entire community can get behind and then 
start developing programs across those different sectors to 
surround people with all the help that they need to enter into 
recovery whenever they are ready. Hope that answers your 
question.
    Senator Murphy. It does. I think that the importance you 
place on flexibility and recognizing that every community is 
different is important. Dr. Harris, I want to talk to you about 
the impact that gun violence has on life expectancy. The data I 
have seen is fairly remarkable. Nationally, the total life 
expectancy loss due to firearms was about 2.5 years. As you 
would imagine, that is a very different number for white 
Americans, about 2.2 years versus Black Americans 4.1 years. 
And it strikes me that while that data is relative to the gun 
violence death itself, the leading cause of death today for 
African-American young men, 15 to 24.
    To the Chief's point, the trauma of being exposed to gun 
violence, especially at an early age, also must have an impact 
on life expectancy, given that we know those early traumas lead 
you into riskier behaviors later in life. So just wanted to get 
a sense of how much research is being done on the impact of gun 
violence, both at the rate of death itself, but also the trauma 
involved in living in violent neighborhoods and how much that 
factors into this national conversation about life expectancy.
    Ms. Harris. Thank you for that question. There sort of 
needs to be a two part answer to this. In the report, we were 
focused on, what was causing the rise in mortality--and there 
is significant evidence showing that states that have looser 
gun laws and more guns have higher rates of suicide and deaths, 
as you said, especially among young adults for whom that is one 
of the leading causes. To the U.S., however, the increase to 
access to firearms we found did not really explain the rise in 
mortality because other cause, other means of suicide, for 
example, were contributing more deaths, like suffocation, for 
example. However it goes without saying that when there is 
greater access to firearms, the deaths that we were examining 
of mortality in this report are higher as well as deaths due to 
violence.
    Now, so that is one part. The second point is the access to 
firearms is clearly an important contributor to violent death 
rates. And as you said, there has been a lot of new research 
around the nature of the victim and the perpetrator and how 
these experiences affect them. But the exposure of family 
members, neighbors in ways in which crime and violence is 
higher. And the one thing that we have found is going back to 
record the importance of communities, which is something that 
everyone has been sort of talking about.
    We think that one of the reasons that we have an increase 
in cardiometabolic deaths, for example, is due to the 
neighborhoods in which people live. People who live in unsafe 
neighborhoods with high crime are--don't have access to open 
spaces to exercise and can't enjoy a lifestyle that will help 
them keep their weight down and avoid obesity. They don't live 
in neighborhoods where they can walk around the corner to the 
grocery store and get fresh foods and fruits.
    It is a--it is a very important problem that the research 
is only now beginning to address because, now for a while 
really--the surveys didn't really include questions about guns 
and guns in the household and being a victim or witnessing a 
violent crime. So I think that the future is going to be able 
to provide a lot of answers along those lines.
    Senator Murphy. Very quickly. I take your point that it 
maybe is not attributed to the recent decline in life 
expectancy rates likely because it has been for a very long 
time a significant contributor to the rate of death in many of 
our communities, in particular communities of color. So thank 
you very much, Mr. Chairman.
    The Chairman. Thank you.
    Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman, and thank you 
for the hearing today and the focus on these disparities. We 
have some startling statistics in my state, I would say they 
are alarming. When you look to the mortality rates of American 
Indians, Alaska native persons aged 20 to 29 years, it is 10.5 
times higher. Alaska Native, American Indian persons aged 
between 30, 39, 11.6 times higher. And that of those in the 40 
to 49, 8.3 times higher compared to their non-Hispanic white 
counterparts. They are really troubling. And this was before 
COVID as well but when you account for these disparities and 
you notice where we have those that are perhaps the most 
vulnerable, it is for Alaska native males and those aged 22 to 
49.
    As I have looked through this report prepared by the 
National Academy of Sciences, and again, I apologize, I am only 
looking at a summary. But I look at the trends. In all cases of 
mortality among males and females and the rates, the thing that 
I find most striking is we have good maps in the lower 48, the 
continental United States, but we don't have Alaska and Hawaii. 
And recognizing that our numbers in Alaska are perhaps so 
disproportionate when we are looking to the disparity.
    I want to ask, and I don't know whether this goes to you, 
Dr. Harris or to you, Dr. Cooke, am I just not looking at the 
full report here? Was--were Alaska and Hawaii included, and we 
just have failed to put them on the map? There are on the map 
of their own because of the awful statistics. But can somebody 
address that, and then I want to get back to some of the issues 
that contribute to these disparities.
    Ms. Harris. I can address that first in terms of the report 
and I am so glad you asked this question because the data show 
exactly what you said that death rates are highest among Alaska 
native and Native Americans. The reason that you don't see them 
in the summary is because the data quality was not there for us 
to include with the other groups over the entire period that we 
examined, which was 1990 to the 2017.
    But the quality of the data are getting better, the 
reporting of the deaths coming from the various states, and so 
we do identify several places in the report. You know, how 
high? Very, very high the risks are of mortality for these 
reasons. And if I could just quickly add, especially in 
response to what Senator Murphy talked about, I want to really 
raise the alarm for what is happening to young adults.
    As you commented, the young adults 25 to 44 are a very high 
risk here. And we see this going into the future. They have 
experienced the greatest increases in drug overdose deaths, as 
well as suicide, as well as the cardiometabolic deaths. I will 
stop there.
    Senator Murkowski. Dr. Cooke, did you want to comment on 
that?
    Dr. Cooke. No, I agree with Ms. Harris.
    Senator Murkowski. Okay. I just want to acknowledge, and 
again when we think about health disparities, so many of the 
other contributing factors that are at play. When we are 
talking about rural Alaska, in many places is extremely rural. 
You have over 80 percent of your communities that are not 
connected by road. You have got small, small communities where 
really in terms of economic opportunity, it is very, very 
limited. And you have got kind of a clash between a subsistence 
lifestyle and being able to get everything on your smartphone 
and find out what is going on in Los Angeles and New York and 
feeling like you are being left out of what is happening with 
the world.
    I think we are seeing some indicators, again, as you have 
suggested, that it is amongst young men who are looking at 
perhaps their surrounding or their life and are choosing 
whether it is drugs, alcohol, suicide, the worst, of course, 
but also we are seeing that reflected in the high levels of 
diabetes or health outcomes there related so often to--what we 
are seeing is a change in diet, moving from a healthy 
subsistence lifestyle to one that is contributing to increased 
diabetes, perhaps cancer, liver disease, kidney disease.
    I haven't really framed a question there other than to just 
share my thanks to the Committee for shining a light on this. I 
am talking about Alaska Natives today, but we know that 
American Indians in so many parts of this country today are 
faced with the same disparities. And it is an issue where we 
are directing a lot of resources finally to the overall health 
and well-being of native people.
    But I think we have so much territory that we have to 
address that it is going to be a real challenge for us to meet 
the need. And if we are not all concerned about what we are 
seeing with young people, particularly our young native men--we 
have all got to be working on this together, so thank you, Mr. 
Chairman.
    The Chairman. Thank you, Senator Murkowski. I recall, I may 
be wrong on this, but in the Pine Ridge Reservation in South 
Dakota, the life expectancy there is something like it is in 
Guatemala. I mean, it is really just unbelievably low. I 
believe Senator Braun is returning, but--it is not the case? 
Why isn't--Senator Collins, if you would like to make your 
closing statement now, that would be appropriate.
    Senator Collins. Okay. I want to express my deep 
appreciation to all of our witnesses today. And Chief, I want 
to encourage you to continue the work that you are doing in 
your county and indeed throughout Maine and throughout New 
England to educate people about substance abuse, to help take 
away the stigma of getting help, and to assist families in 
recognizing when they have a problem in their own family. I 
think that is a huge issue. Dr. Cooke, I want to thank you for 
the hard work you are doing each day. I am going to submit a 
question for the record to you about the increase in suicides 
in rural America. In the State of Maine, we have not been 
immune from that increase, and our most rural counties have the 
highest suicide rates.
    That may speak to poverty, to feeling disconnected, to 
isolation, to higher rates of substance abuse. But I am going 
to be very interested in hearing your thoughts on what we can 
do to get physicians, primary care physicians to incorporate in 
an annual physical or any kind of visit, a mental well-being 
check. I think that is really important. And Doctor, I also 
want to thank you for the research that you have done. It has 
helped to inform this hearing and helps us ensure, Dr. Harris, 
that the work that we do going forward is informed by the best 
possible data that we can get. I think that is absolutely 
critical.
    I will have some additional questions for the record, but I 
did want to take this opportunity to thank each of you for the 
absolutely critical contributions that you are making to help 
us understand the social determinants of good health and also 
to assist us in figuring out policies that will help address 
everything from drug abuse and substance disorders to the 
increase in suicides that I find so troubling. Thank you.
    The Chairman. Well, thank you, Senator Collins. And let me 
thank our wonderful panelists for their remarks today. As I 
mentioned earlier, I think our goal is to try to create a 
society in which our people live long, healthy, happy, and 
productive lives.
    Clearly, I think we have got to focus on issues as to why 
we are behind many other countries with lower income and 
working class people now in many cases are seeing a decline in 
their life expectancy. And what Government policy we can bring 
about to radically change that situation.
    Thank you very much for the work that all of you were doing 
and for helping us shed some light on this serious crisis. 
Thanks to Members of the Committee who have been here. And with 
that, I adjourn the meeting.

                          ADDITIONAL MATERIAL

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                          QUESTIONS AND ANSWERS

    Response by Kathleen Mullan Harris to questions of Senator Casey

                             senator casey
    Question 1. In your testimony, you note that the reversal of 
declining mortality rates initially began among younger white women and 
men living outside large metropolitan areas, but eventually spread to 
most racial and ethnic groups and most geographic areas.

    Have there been efforts to evaluate how these outcomes correspond 
with geographic areas and employment in industries that have been 
impacted by trade? And if so, what does that research show?

    Answer 1. Our report reviewed literature on geographic areas 
impacted by trade more so than industries per se. In general, research 
indicates that trade liberalization policies and increasing import 
exposure are associated with higher death rates due to drug overdose 
and suicide mainly among Whites. For example, research by Author et al. 
(2019) found that the average decade-level rise in import exposure 
induced an additional 64.4 male relative to female deaths per 100,000 
population per decade. Furthermore, manufacturing trade shocks were 
found to cause significant increases in male mortality due to drug and 
alcohol poisoning, HIV/AIDS, and homicide. Increased trade tends to 
result in worker layoffs, plant closings and reduced wages.

        Author, D.H., Dorn, D., and Hanson, G.H. (2019). When work 
        disappears: Manufacturing decline and the falling marriage 
        market value of young men. American Economic Review: Insights, 
        1, 2, 161-178.

    If the Senator or his staff would like to speak with Author for 
more details or estimates, we can provide the connection.

    Below is the relevant text from the Academies Working-Age Mortality 
report on this topic, p. 367:

        Taking advantage of differential exposures to trade 
        liberalization due to Congress's granting of Permanent Normal 
        Trade Relations (PNTR) to China in 2000, Pierce and Schott 
        (2016) found an increase in mortality due to ``deaths of 
        despair.'' Counties in the 75th percentile of exposure to PNTR 
        had a 0.42-0.63 higher suicide mortality rate per 100,000 
        population compared with those in the 25th percentile, 
        accounting for 4-6 percent of the average age-adjusted suicide 
        mortality rate across counties. Likewise, shifting a county 
        from the 25th to the 75th percentile of exposure to PNTR was 
        associated with an almost 30 percent higher mortality rate from 
        accidental poisonings, which include drug overdoses. This 
        increase in drug-related mortality was observed across a large 
        portion of the working-age population (most age bins in the 20-
        54 age group). Importantly, this association was observed only 
        among Whites, consistent with the notion that non-Whites are 
        less affected by job loss (see Chapter 8). Similarly, focusing 
        on young adults ages 18-39, Author, Dorn, and Hanson (2019) 
        found an increase in mortality due to increased import 
        exposure. According to these authors, the average decade-level 
        rise in import exposure induced an additional 64.4 male 
        relative to female deaths per 100,000 population (of each 
        gender) per decade (Author, Dorn, and Hanson, 2019). 
        Furthermore, manufacturing trade shocks were found to cause 
        significant increases in male mortality due to drug and alcohol 
        poisoning, HIV/AIDS, and homicide (Author, Dorn, and Hanson, 
        2019).

    Question 2. I was pleased to see that one of the Committee's policy 
recommendations for addressing the rise in working age mortality was 
for the 12 states that have not expanded Medicaid under the Affordable 
Care Act to do so. My state has benefited enormously from Medicaid 
expansion, which is why I aggressively defended that part of the heath 
care law during the 2017 repeal efforts.

    Given the report's findings on the benefits of Medicaid expansion:

    Question 2(a). What do you believe the report's findings on 
mortality rates would be like had Medicaid expansion never been signed 
into law?

    Answer 2(a). Research by Miller and colleagues in 2019 indicated 
Medicaid expansion has resulted in a 9.4 percent reduction of mortality 
over 4 years. Thus, if Medicaid expansion had never been signed into 
law, mortality rates would have been 9 percent higher over the first 4 
years of Medicaid expansion. See quote from Miller's paper below.

    Question 2(b). How do you believe a repeal of Medicaid expansion 
would impact our Nation's mortality rates moving forward?

    Answer 2(b). Given Miller's finding above, repeal would result in a 
9 percent increase in mortality over 4 years (mortality remains higher 
in non-expansion states, thus, deaths averted due to expansion will 
increase with a repeal). See quote below from Miller's paper.

        ``Our analysis provides new evidence that expanded Medicaid 
        coverage reduces mortality rates among low-income adults. If we 
        assume that similarly sized mortality reductions would have 
        occurred in the non-expansion states, our estimates suggest 
        that approximately 15,600 deaths could have been averted if the 
        ACA expansions were adopted nationwide as originally intended 
        by the ACA.''

        ``Our results therefore indicate that approximately 4,800 fewer 
        deaths occurred per year among this population due to Medicaid 
        expansion, or roughly 19,200 fewer deaths over the first 4 
        years alone.''

        Miller, S., Altekruse, S., Johnson, N., and Wherry, L.R. 
        (2019). Medicaid and Mortality: New Evidence from Linked Survey 
        and Administrative Data. Working Paper No. 26081. Cambridge, 
        MA: National Bureau of Economic Research.

    If the Senator or his staff would like to speak with Miller for 
more details or estimates, we can provide the connection.

    Below is the relevant text from the Academies Working-Age Mortality 
report on this topic, p. 382:

        Medicaid expansion has been associated with a roughly 9 percent 
        reduction in all-cause mortality among working-age adults 
        exposed to the policy change; this effect appears to be growing 
        with time and is estimated to be saving the lives of thousands 
        of working-age Americans each year (Miller et al., 2019). 
        Another study found that expansion states have experienced a 6 
        percent reduction in opioid overdose deaths and an 11 percent 
        reduction in heroin-related deaths (Kravitz-Wirtz et al., 
        2020). Individuals in states that expanded Medicaid coverage 
        also have experienced better health outcomes relative to those 
        in states that deferred expansion (Antonisse et al., 2018). In 
        a study comparing Medicaid expansion states (Kentucky and 
        Arkansas) with a nonexpansion state (Texas), expansion was 
        associated with a $337 per capita reduction in annual out-of-
        pocket spending, significant increases in preventive health 
        visits, and a 23 percent increase in the proportion of 
        respondents who described their health as ``excellent'' 
        (Sommers et al., 2017).
                                 ______
                                 

       Response by Robert MacKenzie to questions of Senator Casey

                             senator casey
    Question 1. Like Maine, my own State of Pennsylvania made 
significant progress in addressing opioid use disorder prior to the 
pandemic, only to see many of those gains reversed during the COVID-19 
pandemic. Although I hope that we do not experience another, similar 
pandemic during my lifetime, what do you feel are the ``lessons 
learned'' from the pandemic for SUD treatment efforts, and what do you 
feel we need to do differently next time to ensure that our gains 
against substance use disorder are not erased?

    Answer 1. SUD is a disease of isolation. With COVID-19 we were 
forced to isolate and it had an immediate impact on those suffering 
with SUD. The opposite of addiction is connection. Whatever gains we 
had made pre-pandemic were severely impacted and those connections were 
lost, and in turn, lives were lost. Many services that had been 
available were no longer possible as in-person treatment and meetings 
were non-existent or changed to an on-line platform. Many of those 
suffering with SUD did not have the ability to have online resources. I 
believe it is vital for organizations to have contingency plans to keep 
in-person meetings and/or to update infrastructure as so space can 
accommodate for social distancing and updated HVAC systems updated with 
filtration systems in order to eliminate airborne pathogens. Outdoor 
meetings are contingent alternatives where possible which many sites 
have adopted.

    Having a media program prepared to educate communities the need to 
watch out for one another, specifically one that are suffering from SUD 
as so loved once and affected others can check on or check in with 
those at risk during times of isolation. We use old cell phones for 
domestic violence victims and maybe there is an option to extend that 
to those at risk as so there is connection. Make and/or increase the 
availability of Naloxone to the public.

    I believe it is vital for those agencies giving treatment, such as 
a Vivitrol injection (a medication that is utilized to prevent relapse, 
typically from opioid use disorder) have a back-up plan or alternate 
site that is available to provide such injections if they are not able 
to continue in times, such as a pandemic. It is my understanding that 
pharmacists were a potential option to continue the treatment but some 
state laws prohibited them from doing so.

    Question 2. Thank you for your efforts to reduce stigma related to 
SUD as a way of improving access to treatment. As you are aware, this 
stigma is firmly rooted within many organizations and communities, and 
can be difficult to dispel. What advice do you have for public 
officials, community activists and others who would also like to work 
to reduce the stigma associated with this condition?

    Answer 2. I have done an estimated 100 or more talks on SUD, 
focusing on stigma reduction and have received positive feedback 100 
percent of the time. I do not say this to gloat or make it sound as 
though I am a great speaker. I believe it is a combination of things 
that have contributed to the success of these talks.

    Having those speak who are in professions such as physicians, law 
enforcement executives, political heads and others whom are passionate 
about SUD as these officials already have established credibility with 
the audience.

    The audience must be educated of SUD being a disease. For those in 
the audience that may not feel as though SUD has affected them 
directly, I discuss the impact of SUD to our society, in lives lost but 
also as to the billions of dollars it costs us each year. (I typically 
break the costs down nationally, to a community level and to an 
individual taxpayer costs.) I get great feedback on this. With regard 
to lives lost, I use national stats but I also use statewide and local 
statistics on OD deaths.

    Having those speakers, such as myself who have had loved ones 
suffering from SUD or have lost a loved one to an OD are very powerful 
as it makes it real and that it can happen to anyone.

    One of the most powerful additions to speaking engagements is 
bringing in someone who is in recovery that is willing to share their 
story and answer questions. When the audience has the opportunity to 
hear from someone that is open to share their journey, which is 
typically a very dark place, but to see how far they have come and how 
recovery is possible gives the audience that sense of hope and that 
recovery is possible. This really helps reduce stigma.

    Having a call to action and asking that the audience members to be 
part of the solution. Reduce stigma by talking to loved ones and 
friends, taking Naloxone class, (which I typically have one at the end 
of the program), asking them to encourage others to participate in 
similar forums as we need to work together to make a difference and 
save lives.

    Calling on civic organizations such as local Rotary Clubs, Lyons 
Clubs, Kiwanis Clubs, etc. . . All of these organizations typically 
want to help better the lives of the communities they serve and would 
love to be involved.

    Always invite the media, both broadcast and print. Media outlets 
always look for local stories and when organizations invite them in it 
not only gets the story out to the communities, it reduces stigma as 
their viewers and readers see good organizations working on initiatives 
that were not generally talked about due to stigma.
    In my experience the more people that are educated and exposed to 
those in recovery makes a significant reduction of stigma. Once you 
reduce stigma and educate how community members can be involved it 
truly prepares your communities to be recovery ready.
                                 ______
                                 
    [Whereupon, at 11:10 a.m., the hearing was adjourned.]

                                  [all]